1. Assessment in Life Participation Approach to Aphasia
NOTE: The associated document, “Course Module: Assessment in Life Participation Approach to Aphasia”, contains information regarding relevant standards/guidelines, learning objectives, additional learning materials, and assessment activities. The document, “Summary of Assessment References” contains the references.

2. Academic Module Sponsors:

3. Academic Module Committee

4. About Aphasia Access Received its 501c(3) designation in May 2014
Membership includes representation from 33 states and 5 Canadian Provinces. The Life Participation Approach to Aphasia (LPAA) is the core philosophy.
Produces videos, webinars and podcasts that are used internationally to educate speech-language pathologists, healthcare professionals, students, nonprofit board members and community leaders.
Advocates for aphasia care and communication access throughout health care.
About Aphasia Access

5. Assessment in Life Participation Approach to Aphasia
How can SLPs assess people with aphasia using the LPAA?

6. Target Audience
This presentation has been developed for speech-language pathology (SLP) students and current practitioners and is one portion of a series of LPAA academic modules for adoption in pre-professional and continuing education.

7. LPAA Curriculum Modules
The Working Group on Academic Curriculum of the Education and Research Committee of AphasiaAccess has developed this module to
Describe principles and processes for assessment when adopting the Life Participation Approach to Aphasia

8. Learning Objectives
Upon successful completion of this learning module, participants will be able to:
Differentiate between using the LPAA model from impairment-based models of assessment
Apply the LPAA model to assessment processes and procedures for people with aphasia

9. This module will cover…
What is the Life Participation Approach to Aphasia (LPAA)?
Why use the LPAA in assessment of people with aphasia?
When? Where? and How can SLPs
use the LPAA in assessment of people with aphasia?

10. 1. What is the Life Participation Approach to Aphasia (LPAA)?
A brief summary

11. Life Participation Approach to Aphasia (LPAA)
LPAA is an underlying philosophy which supports treatment for individuals with aphasia (LPAA project group, 2000).
LPAA Core Values
Goal is enhancement of life participation
Services are available to all affected by aphasia
Changes in the environment are essential to participation
Success is measured by documented life changes
Services are available as needed at all stages

12. LPAA
LPAA places life concerns of people with aphasia at the center of all decisions.
Clinicians strengthen daily participation in activities of their client’s choice.
The clinician works not only on communication but also on establishing and maintaining social links…for it is within this environment that one communicates.

13. LPAA expands the role of the SLP
Goal: To overcome challenges with participating in activities
SLP
Coach
Problem Solver
Support Person
PWA
Communication Partner

14. 2. Why use LPAA in assessment of people with aphasia?
A foundation in best practices

15. LPAA Assessment is best practice
Aligns with practice guidelines
ASHA Scope of practice, Aphasia United, Australian Aphasia Pathway
Complements impairment level assessment of language
(Hinckley, 2015)
Incorporates activity, participation, environmental and personal factors
Recognizes critical role of patient-reported outcomes
(Boothe & Richardson, , 2011)

16. LPAA assessment is purposeful
Determines current activity and participation levels
Identifies future activity and participation goals
Evaluates factors that impact participation: communication, physical, personal and environmental factors
Reveals immediate and future needs for communication
Assesses social connectedness and social support
Considers emotional well-being and quality of life
Guides further assessment and treatment

17. LPAA assessment is personally meaningful
“What do people with aphasia want ?”
People with aphasia and their families want
Activity and participation goals (Worrall et al., 2011)
People with aphasia want
to improve communication....and… return to valued activities (hobbies, returning to work, to travel) (Rohde,Townley-O'Neill et al., 2012)

18. LPAA assessment is relationship centered
A change in perspective from impairment-based to LPAA assessment is based upon relationship centered care.
Relationships in health care include the personhood of the participants
Affect and emotion are important components of these relationships
All health care relationships occur with reciprocal influence
Genuine relationships in health care are morally valuable
(Beach, Inui & Relationship-Centered Care Research Network, 2006)

19. LPAA Assessment is consistent with the WHO-ICF
Impairments: problems in body function or structure
Activity: doing a task or action.
Participation: involvement in a life situation.
Environmental Factors: physical, social and attitudinal
Personal Factors: age, coping styles, education

20. LPAA Assessment is informed by A-FROM Aphasia Framework for Outcome Measurement (Kagan et al., 2007)
A-FROM is conceptualized around four domains
Impairment
Participation
Environment
Personal factors
Premise focuses on
increasing access while reducing barriers in healthcare
facilitating participation in personally relevant activities

21. A-FROM (Kagan et al., 2008) Considers: Conversations Relationships
Leisure activities
Volunteer opportunities
Community activities
Image retrieved 4/24/17 from:
Considers:
Confidence
Self-esteem
Identity and autonomy
Considers:
Family’s skills
Communication support
Friends’ attitudes and knowledge
Adaptation to activities
Considers:
Language activities to support specific roles
Vocabulary for KEY interests
Scripts for specific activities
A-FROM (Kagan et al., 2008)

22. Comparison of impairment-oriented and LPAA assessment (Whiteside, 2017, LPAA Academic Module)
Impairment-oriented Assessment
LPAA Assessment
Language functions intrinsic
to the individual
Spoken language production
Understanding spoken language
Written language production
Understanding written language
Modalities
All domains of living with aphasia
Language & communication strengths
Participation goals
Environment and context
Personal factors
Emotional well-being

23. 3. When, where, and how do SLPs apply LPAA assessment?
A primer in LPAA assessment

24. Times for LPAA assessment
Assessment using the LPAA takes place across the life-span of a person living with aphasia (Simmons-Mackie, King, & Beukelman, 2013).
Soon after onset in acute care
During active rehabilitation
Any time new needs arise

25. Example: After onset in Acute Care
When the SLP arrived to assess Mr. A’s communication, his wife was sitting tearfully next to him. Mr. A had been unable to read his menu and did not like anything on his food tray.
Using the process of Contextual Analysis, the SLP observed:
ENVIRONMENTAL factors (text-based menu)
PERSONAL factors (food preferences and caring spouse) and
LANGUAGE factors (reduced reading comprehension).
Using a process of Dynamic Assessment, a 6-square picture menu of breakfast items was used.
Mr. A selected preferred foods.
His wife observed this supported conversation approach.
Identified LPAA Goal: Mr. A will select his preferred food items using a pictographic menu

26. Places for LPAA assessment
Assessing using the LPAA takes place within all settings where the SLP meets people with aphasia.
Hospital (McCooey - O’Halloran et al., 2004)
Skilled nursing facility
Home (Haley et al., 2010)
Outpatient clinic
Aphasia Center (Kagan et al., 2008)
Community (Dalemans et al., 2010) 

27. Example: Home Care
Mr. and Mrs. B. talked with the home care SLP about how life had changed since coming home from the hospital.
Using a patient report tool, the Communication Activities Checklist (COMACT) (Cruice, 2001, Cruice et al., 2010), the client’s communication interests were assessed. The SLP determined that Mr. B. wanted to read more.
Using the A-FROM framework, the SLP considered:
ENVIRONMENTAL factors (He and his wife read in the living room every evening)
PERSONAL factors (They missed the social closeness of reading together) and
LANGUAGE factors (Significantly reduced reading comprehension).
Identified LPAA Goal: To enjoy reading together with wife using audio books from public library

28. Assessment can be ongoing, as new needs arise
What new participation need or interest has the person identified?
What are possible communication participation barriers?
Needs access to public transportation system
Able to use phone to reserve the metro van?
Wants to volunteer on a community board
Able to listen to a group discussion and take notes?
Needs a new apartment
Able to read an apartment search phone app?

29. Methods for assessment in LPAA
1. Standardized Assessments
empirically developed with statistical reliability and validity
2. Self-Report/Family/ or SLP Report Measures
rating scales, inventories or questionnaires
3.. Ethnographic Interviewing / Biographic Narrative
open-ended questions, restatement, and clarification
4. Observation and Contextual Analysis
variables affecting and interacting with communication participation
5. Dynamic Assessment
real-life situation task assessment; treatment applied and changes noted

30. Examples of assessment
The following 5 slides will highlight brief clinical examples of LPAA assessment using:
Standardized Assessment Tool
An Interviewing Process
Self-Report Tools
Contextual Analysis
Dynamic Assessment

31. LPAA Assessment: 1) Standardized Tool
Purpose
To reveal immediate needs for communication participation
Mr. A, 78, living alone after recent CVA
Tool
Communication Activities of Daily Living - 3 (Holland, Fromm, & Wozniak, 2018)
Outcome
Identified impairment in reading prescription instructions; Mr. A needs to manage his medications at home independently.

32. LPAA Assessment : 2) Interviewing
Purpose
To identify the individual’s life participation goals Mrs. B, age 63, 3 years post CVA
Process:
Ethnographic Interviewing (Simmons-Mackie & Damico, 2001)
Counseling/coaching (Holland & Nelson, 2013)
Outcome:
Identified Mrs. B’s participation goal: To present testimony about her recovery in her church
WHO-ICF participation domain: d930 Religion and spirituality (WHO-ICF, 2003; Pollens & Glista, 2016)

33. LPAA Assessment: 3) Self report Tools
Purpose
To evaluate current impact of aphasia on participation and emotional well-being
Mr. C, 42 year old teacher, anomic aphasia, 2 years post CVA, unable to return to work.
Tools
Assessment for Living with Aphasia (ALA)
Depression screening (Visual Analog Mood Scale)
Outcome
ALA identified lowest scores in the domain of personal/psychosocial factors; positive screen for depression

34. LPAA Assessment: 4) Contextual Assessment
Purpose
To identify impact of environmental factors
Mr. D, age 27, 1 year post CVA, wants to schedule rides from local paratransit system
Process
Real-life situation task assessment in natural context
Outcome
When Mr. D attempted to use the telephone system, the ride dispatcher was unable to understand Mr. D’s ride requests. Dispatcher did not demonstrate supportive communication approaches.
Pollens & Glista, 2016)

35. LPAA Assessment: 5) Dynamic Assessment (Hersh et al
LPAA Assessment: 5) Dynamic Assessment (Hersh et al., 2013; Hersh, 2012)
Pollens & Glista, 2016)
Purpose
To evaluate current impact of aphasia on participation and to guide treatment
Mrs. E, 58 with nonfluent aphasia, 3 months post onset
Process
At the skilled nursing facility, the Interprofessional Team meeting noted that Mrs. E was not following safety instructions for use of her new walker. This was a barrier to her goal to reside in her own home. The SLP observed PT working with Mrs. E and assessed her ability to follow the spoken instructions. SLP then provided key word visual support to determine impact on following safety instructions.
Outcome
Mrs. E’s personal goal of discharge to her home will require treatment of communication strategies for increasing comprehension of safety instructions.

36. Program-specific “choice” can be another assessment tool
Many Aphasia Centers and Aphasia Groups offer people with aphasia choices from menus of participation activities.
Many people with aphasia and their care partners state what they want to do in their lives (Worrall et al., 2011).
The client’s choices can reveal participation needs, interests, and hopes (Glista & Pollens, 2007).

37. Client Choice Please rate these
Do you want to teach other people about aphasia?
Not at all Maybe Very much
Do you want to use the internet and discuss current events?
Do you want to improve your spelling and writing?
Do you want to visit an Art Museum and discuss the paintings?
(Glista & Pollens, 2007)

38. Additional variables may influence SLP decisions in methods of assessment (Coppens & Simmons-Mackie, 2018)
Preferences of the person with aphasia
Age and life situation/role of the person with aphasia
Level of communication ability
Cognitive abilities
Sensory functioning
Availability of time or resources
SLP knowledge, experience, and expertise

39. 4. What are some tools used in LPAA assessment?
A selection of assessments and interviews

40. Interviewing…Educating…Counseling
How do we listen to truly hear what clients and families want?
What’s one thing that will truly make a difference?
What is happening in your life - now?
What are your hopes for the future?
Biographic narrative (Corsten et al., 2013)
Coaching/Active listening (Holland & Nelson, 2014)
Ethnographic interviewing (Simmons-Mackie & Damico, 2001)
Life story narratives (Shadden, 2007; Hinckley, 2015)

41. Assessments
A variety of assessments tools and processes can be used within the LPAA. A selection of assessment descriptions follows in alphabetical order.
For a comprehensive list see…
Brandenburg, C., Worrall, L., Rodriguez, A., & Bagraith, K. (2015). Crosswalk of participation self-report measures for aphasia to the ICF: What content is being measured? Disability and Rehabilitation, 37(13),
For a comprehensive discussion of assessment related to Quality of Life…
See Hilari & Cruice (2017)

42. Assessment for Living with Aphasia (Aphasia Institute, 2010)
TOOL
Assessment for Living with Aphasia
(Aphasia Institute, 2010)
Description
Pictographic self-report measure of aphasia-related quality of life across multiple domains that impact life with aphasia
Measurement
Overall score of person’s perceptions of life with aphasia. Also domain specific scores (language, participation, personal/psychosocial factors and environmental factors).
Example Result
Person with aphasia expresses high need to resume reading for pleasure in every day activities.

43. TOOL Aphasia Communication Outcome Measure (ACOM) (Hula et al., 2015)
Description
Person with aphasia self reports communicative functioning
Measurement
Measures perception of how effectively person with aphasia completes communication-related behaviors, tasks, activities, and life situation.
Example result
Person with aphasia indicates she does not talk very effectively with her best friend and care partner.

44. Burden of Stroke Scale – BOSS (Doyle et al., 2003)
TOOL
Burden of Stroke Scale – BOSS (Doyle et al., 2003)
Description
Person with aphasia self reports health status difficulty in functioning across mobility, self-care, swallowing, energy and sleep, communication, cognition, and social relations.
Measurement
Scores of physical limitations, cognitive limitations, and psychological distress obtained.
Example result
Person with aphasia indicated difficulty communicating with a familiar person on the phone.

45. TOOL Communication Abilities of Daily Living – 3 Description
(Holland, Fromm, & Wozniak, 2018)
Description
The clinician assesses 1. Reading, writing, and using numbers 2. Social interaction 3. Contextual communication 4. Nonverbal communication 5. Sequential relationships 6. Humor / metaphor /absurdity 7. Internet basics
Measurement
A raw score is obtained from which percentile rank and stanine score are available.
Example Result
Person with aphasia was successful in using multiple modalities to express ideas.

46. TOOL Communication Activities Checklist COMACT Description Measurement
(Cruice, 2001; Cruice et al., 2010)
Description
Person with aphasia self-reports engagement in types of communication activities.
Measurement
Talking, listening, reading, and writing activities are identified, and frequencies are tallied.
Example result
Person with aphasia expresses wish to increase talking with her neighbor from once per month to once per week.

47. TOOL
Communication Confidence Rating Scale for Aphasia - CCRSA (Babbit & Cherney, 2010)
Description
Person with aphasia rates self confidence in 10 examples of social and functional communication.
Measurement
Determines how self-confident the person with aphasia feels in communication and the change in self confidence over time.
Example result
Person with aphasia rates self as “moderately” confident in ability to talk with other people.

48. TOOL Communication Disability Profile - CDP Description Measurement
(Swinburn & Byng, 2006)
Description
Person with aphasia self rates activity, social participation, external influences, and emotional consequences. Pictures facilitate discussion with clinician.
Measurement
Measures of the impact of aphasia by obtaining scores for individual items.
Example result
Person with aphasia identified she could not do her own grocery shopping independently.

49. TOOL Communication Effectiveness Index – CETI Description Measurement
(Lomas et al., 1989)
Description
Communication partner rates functional change in communicating basic needs, life skills, and social needs through questionnaire.
Measurement
Change in functional communication over time is recorded for 16 items.
Example result
Spouse reported change in “getting someone’s attention” from not at all able to same as before stroke.

50. TOOL
Community Integration Questionnaire – CIQ (with or without pictographs)
(Dalemans et al., 2010)
Description
Person with aphasia selects how often an activity is performed in area of home integration, social integration, and productive activities. Originally developed for TBI survivors; adapted for persons with aphasia
Measurement
A raw score from is obtained; the higher the score, the more community integration reported.
Example result
Person with aphasia reported not grocery shopping for family; she wants to resume responsibility.

51. TOOL L!V Cards (Life Interests and Values Cards) Description
(Haley et al., 2010)
Description
Communicate with person with aphasia or family/friend about valued life activities. Drawings on cards depict life activities in four categories: Home & Community, Creative & Relaxing, Physical, and Social
Measurement
Determine list of “wants to do more” activities in each area
Example result
Person with aphasia chose camping and traveling as a family life activity to resume.

52. TOOL
Quality of Communication Life Scale - ASHA QCL (Paul et al., 2004)
Description
Person with aphasia self rates the impact of aphasia on relationships; communication; interactions; participation in social, leisure, work, and education activities; and overall quality of life.
Measurement
Vertical analog scale is marked from low to high points using key words and pictures which reflect perceptions of life quality, social roles, and interactions.
Example result
Person with aphasia chose lowest point of the scale to rate, My role in the family is the same.

53. TOOL Social Activities Checklist - SOCACT Description Measurement
(Cruice et al., 2010)
Description
Person with aphasia is interviewed to quantify range and frequency of involvement in social activities.
Measurement
Weekly, biweekly, monthly, rarely, not at all and not applicable used to collect information about social activity and participation.
Example result
Person with aphasia wants to go to church with his spouse every week.

54. TOOL Stroke and Aphasia Quality of Life Scale SAQOL-39 Description
(Hilari et al., 2003)
Description
Persons with aphasia evaluate function in physical, psychological, communication, and energy.
Measurement
Difficulties are reported for 39 items on a 5-point scale using two formats, e.g. could not do it at all/no trouble at all; definitely yes/definitely no.
Example result
When asked, During the past week, did you feel withdrawn from other people, person with aphasia chose “definitely yes.”

55. TOOL Visual Analog Mood Scale (Stern, 1997) Description Measurement
Person with aphasia selects from simple schematic faces to report mood states.
Measurement
Mood states include choices of sad, afraid, angry, tired, energetic, happy, and confused
Example result
Person with aphasia selects faces depicting sad and afraid during three consecutive sessions.

56. TOOL WHO-ICF checklist Description Measurement Example result(
Description
This checklist of major categories of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization can be a practical tool to elicit and record information on the functioning and disability of an individual.
Measurement
Through an interview, version 2.1a, Clinician Form, part 2 collects information about performance and limitations of activities.
Example result
Person with aphasia has problems with holding conversations with family and friends.

57. Additional Resources

58. Additional Resources

59. 5. How do SLPs use LPAA assessment information to design treatment?
An AphasiaAccess module on LPAA Treatment

60. Summary
When using the LPAA approach to assessment, the SLP addresses the
Language,
Participation,
Environmental, and
Personal Factors domains.
The LPAA approach to assessment results in treatment models which can address all of these factors.

61. Comprehensive LPAA treatment “I want to learn to email with my family”

62. See AphasiaAccess LPAA Treatment Module

63. Questions?
How will you use the LPAA to assess people with aphasia?

64. Summary of Assessment References
A complete list of references can be found at